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-=-=-=-=-=> [這篇文章最後由JuanFe在 2018/08/15 03:39pm 第 1 次編輯] 4 Case 4 scenario (acute chest pain) Doorway Information About patient The patient is a 29-year-old woman with known sickle cel anemia who comes to the emergency department due to chest pain Vital signs . Temperature : 38.5’C (101.3F) . Blood pressure: 120/75 mmHg . Pulse : 110/min . Respirations : 22/min Clinical images Electrocardiogram T-S slightly upward ? Basic differential diagnosis Hematologic . chest syndrome due to sickle cell anemia Cardiovascular . Pericarditis . Acute coronary syndrome Pulmonary . Pneumonia . Pulmonary thromboembolism Musculoskeletal . Costochondritis . Salmonella osteomyelitis Other . Panic attack ————— Case 4 sim pt. instructions if the doctor asks you about anything other than these , just say “ no, ‘ or provide an answer that a normal patient might give. You are 29-year -old women who comes to the emergency department with chest pain. History of present illness . Pain started 12 hours ago . Pain located in the middle of the chest and dose not move. . Pain started slowly bit is increasing and is now 7-8/10 in severity. . Pain worse with any movement or deep breathing. . Took acetaminophen , which reduced the pain slightly. . Fever as high as 38.3’C (101F) . caught with green sputum , and imild shortness of breath for the last 3 days. . No blood in the sputum or recent chest trauma. Review of the systems . No used , vomiting , diarrhea , or abdominal pain. . No leg pain or swelling . No back pain . No urinary symptoms . Last menstrual period was 2 weeks ago Past medical / family / social history . Sickle cell anemia: Diagnosed in childhood ; had mild pain episodes at that time. 1 transfusion(age 18). Admitted once for abdominal pain 5 years ago that resolved with supportive care in hospital. . No surgires . No pregnancies . Medications : Birth control pill , acetaminophen as needed . Allergies ; No drug allergies . Mother also has sickle cell anemia; brother and father are healthy . Occupation ; Teacher . Single , sexual active with 1 boyfriend and use condoms regularly . Tobacco : No . Alcohol : No . Recreational drugs : No Physical examination Head and neck: . No redness or exudates in the mouth /pharynx . No enlarged lymph nodes Chest/lungs: . No tenderness to palpation of the chest wall . Clear to auscultation bilaterally Heart; . Regular rhythm with borderline tachycardia . No murmurs Abdomen: . Nontender , non distended . Normative bowel sound throughout . Tympanic to percussion . No hepatosplenomegaly Extremities: . No cyanosis . No tenderness in the legs You should also try to breath a little faster than normal to rate near 20/min . the rest of the examination is normal. ————— Case 4 sim. pt. checklist Following the encounter , check which of the following items were performed by the examinee. History of present illness/ review of the system . Asked about the location of pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the origin and duration off pain . Asked about the progression of pain . Asked about any radiation of pain . Asked about any radiation of pain . Asked about the aggravating/ relieving factors . Asked about associated symptoms , especially: - Nausea - Fever - cough - Shortness of breath . Asked about precipitating gators of sickle cell crisis (eg, diarrhea a, dehydration , stress) . Asked boy history of chest trauma . Asked about nay leg pain / swelling / redness . Asked about blood in the urine . Asked bout prior blood transfusion Past medical / family / social history . Asked about any similar problems in the past . Asked about other past medical issues . Asked about previous hospitalizations and surgeries . Asked about menstrual / reproductive history . Asked about current medications (prescription and over the counter) . Asked about any medication allergies . Asked about family history of sickle cell anemia , heart problems , and blood clots . asked about tobacco , alcohol , and drug use . Asked about occupation Examination . Examinee chased hands before examination . Examined without gown , not through gown . Examined the oral cavity . Examined for enlarged lymph nodes . Performed inspection and palpation of the chest . Performed palpation of area . Auscultated the lungs and heart . Palpated abdomen (superficial and deep) . Examined hands and fingers . Examined legs for tenderness Counseling . Explained the physical findings and possible diagnosis . Explained the complications of sickly cell disease (infections , hypoxia can precipitate pain) . Exclaimed further workup . Discussed the importance of avoiding hypoxemia and maintaining hydration Communication skills and professional conduct . Knocked before entering the room . Introduced self and greeted you warmly . Used your name to address you . Paid attention to het you said and maintained good eye contact . Asked few open-ended questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting . Used plain English rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Expressed empathy and made appropriate reassurances Different diagnosis . Chest syndrome due to sickle cell anemia . Pneumonia . Costochondritis . Pericarditis . Pulmonary thromboembolism . Salmonella osteomyelitis Diagnostic study / studies . CBC with differential . Urinalysis . Sputum Gram and culture . Blood cultures . Chest x-ray . ECG (provided with doorway information) ————— Case 4 clinical summary Clinical Skill Evaluation Case 4 Clinical Note The following represents a typical note for this patient encounter. The details may vary depending on the information given by the simulated patient. History ; Describe the history you just obtained form this patient o. Include only information (pertinent positive and negatives) relevant to tis patient’s problem(s). . 29-yo female with history of sickle cell anemia and 12 hours of acute -onset chest pain. . Grade; increase in pain to 7-8 on a scale of 10 over the past 12 hours. . Pain is worse with movement and respiration and improved with acetaminophen. . 3 days of fever to 38.3’C (101F) , cough productive of green sputum , and mild shortness of breath. ROS: No nausea , vomiting, trauma to chest , dysuria , diarrhea , leg swelling , or leg pain. PMHx : Admitted once 5 years ago for abdominal pain that resolved PSHx : None Meds : Birth control pills , Tylenol PRN Allergies : Noen FHx : Mother has sickle cell anemia SHx : Denies use of tobacco, alcohol , and elicit drugs , Had a blood transfusion as a child. ECG shows sinus tachycardia with no diagnostic abnormalities Physical examination: Describe any positive and negative findings relevant to this patient’s problem(s). Be careful to include only those parts of the examination performed in this encounter. . Vital signs : Temperature , 38.5’C (101’3F); blood pressure , 120/75 mmHg; pulse , 110/min; and respirations , 2/min . HEENT : Oropharynx without erythema or exudates . Neck : No cervical lymphadenopathy , trachea midline . Lungs : CTA bilaterally , no chest tenderness to palpation . Heart : RRR without M/R/G . Abdomen : Contender , non distended , normative bowel sounds thought ; tympanic to percussion , no hepatosplenomegaly . Extremities : No cyanosis, clubbing , or edema ; no swelling or tenderness in the legs Data interpretation; Based on what you have learned form the history and physical examination, List up to 3 diagnosis that might explain this patient’s complaints(s). List your diagnosis form poset to least likely . For some cases , fewer than 3 diagnosis will be appropriated then , enter the positive ro negative findings form the history and the physical examination (if present) that support each diagnosis . Lastly ,list initial diagnostic studies (if nay) you would order for each listed diagnosis(e.g., restricted physic examination maneuvers, laboratory testes , imaging , ECG, etc) Diagnosis #1 : Acute chest syndrome History finding(s) . Acute -onset chest pian . Shortness of breath . History of sickle cell anemia Physical Exam finding(s) . No chest pain or palpation . Fever Diagnosis#2 : Pneumonia History finding(s) . Fever . Cough productive of green sputum . Shortness of breath Physical Exam finding(s) . Fever . Tachypnea Diagnosis#3 ; Pulmonary embolism History finding(s) . Pleuritic chest pain . Fever . Shortness of breath . Birth control pills Physical Exam finding(s) . Fever . No chest tenderness ot palpation Diagnostic Studies . chest x-ray . ABG . Blood cultures . CBC with differential -=-=-=-=-=>
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